Journal of Behavioral Medicine

, Volume 35, Issue 2, pp 200–210

Co-occurrence of obesity and patterns of alcohol use associated with elevated serum hepatic enzymes in US adults

  • James Tsai
  • Earl S. Ford
  • Guixiang Zhao
  • Chaoyang Li
  • Kurt J. Greenlund
  • Janet B. Croft
Article

Abstract

The aim of this cross-sectional study was to present nationally representative findings on the co-occurrence of obesity and specific patterns of alcohol use associated with elevated serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyltransferase (GGT) among adults in the United States. We analyzed data from 8,373 adults aged ≥ 20 years who participated in the 2005–2008 National Health and Nutrition Examination Survey. We produced prevalence ratios by using the co-occurrence of obesity (i.e., body mass index ≥ 30.0 kg/m2 or waist circumference ≥ 102 cm in men and ≥ 88 cm in women) and specific patterns of alcohol use (i.e., non-drinkers, non-excessive drinkers, and excessive drinkers) as a predictor; elevations in serum ALT, AST, and GGT were used as an outcome variable while adjusting for covariates in multivariate regression models. Approximately 34.7% of adult men and 38.6% of adult women in the United States had co-occurrence of obesity and any alcohol use, including 16.4% of men and 9.8% of women who had co-occurrence of obesity and excessive drinking during 2005–2008. When compared to male non-drinkers without obesity after multivariate adjustment, male excessive drinkers with obesity were 3.08 (95% CI: 1.80–5.28), 2.42 (95% CI: 1.80–3.26), and 3.15 (95% CI: 1.82–5.46) times more likely to exhibit elevated serum ALT, AST, and GGT, respectively. Similarly, when compared to female non-drinkers without obesity, female excessive drinkers with obesity were 2.36 (95% CI: 1.38–4.04), 3.27 (95% CI: 1.85–5.78), and 3.43 (95% CI: 2.19–5.40) times more likely to have elevated serum ALT, AST, and GGT, respectively. The co-occurrence of obesity and excessive drinking may place adults at an increased risk for potential liver injury. Our study findings provide support for evidence-based clinical and population-based interventions that integrate health behavior change among adults who have these co-occurring risk factors.

Keywords

Obesity Abdominal obesity Alcohol use Transaminase Aminotransferase Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Gamma-glutamyl transferase (GGT) 

References

  1. Adams, L. A., Knuiman, M. W., Divitini, M. L., & Olynyk, J. K. (2008). Body mass index is a stronger predictor of alanine aminotransaminase levels than alcohol consumption. Journal of Gastroenterology and Hepatology, 23, 1089–1093.PubMedCrossRefGoogle Scholar
  2. Alatalo, P., Koivisto, H., Hietala, J., Puukka, K., Bloigu, R., & Niemela, O. (2008). Effect of moderate alcohol consumption on liver enzymes increases with increasing body mass index. The American Journal of Clinical Nutrition, 88, 1097–1103.PubMedGoogle Scholar
  3. Alatalo, P., Koivisto, H., Puukka, K., Hietala, J., Anttila, P., Bloigu, R., et al. (2009). Biomarkers of liver status in heavy drinkers, moderate drinkers and abstainers. Alcohol and Alcoholism, 44, 199–203.PubMedCrossRefGoogle Scholar
  4. APHA. (2008). Alcohol screening and brief intervention: A guide for public health practitioners. Washington DC: National Highway Traffic Safety Administration, US Department of Transportation. American Public Health Association (APHA) and Education Development Center, Inc.Google Scholar
  5. Barros, A. J., & Hirakata, V. N. (2003). Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models that directly estimate the prevalence ratio. BMC Medical Research Methodology, 3, 21.PubMedCrossRefGoogle Scholar
  6. Breslow, R. A., & Smothers, B. A. (2005). Drinking patterns and body mass index in never smokers: National Health Interview Survey, 1997–2001. American Journal of Epidemiology, 161, 368–376.PubMedCrossRefGoogle Scholar
  7. Calle, E. E., Rodriguez, C., Walker-Thurmond, K., & Thun, M. J. (2003). Overweight, obesity, and mortality from cancer in a prospectively studied cohort of US adults. The New England Journal of Medicine, 348, 1625–1638.PubMedCrossRefGoogle Scholar
  8. CDC. (2007). Centers for Disease Control and Prevention (CDC). Surveillance for acute viral hepatitis—United States, 2007. Morbidity and Mortality Weekly Report, 58, 1–27.Google Scholar
  9. CDC. (2009a). The guide to community preventive services. Centers for Disease Control and Prevention. Atlanta, Georgia. URL: http://www.thecommunityguide.org/pa/index.html.
  10. CDC. (2009b). Recommended community strategies and measurements to prevent obesity in the United States. Morbidity and Mortality Weekly Report, 58, 1–26.Google Scholar
  11. CDC. (2010). National health and nutrition examination survey. Centers for Disease Control and Prevention (CDC). Atlanta, Georgia. URL: http://www.cdc.gov/nchs/nhanes.htm.
  12. Chang, Y., Ryu, S., Sung, E., & Jang, Y. (2007). Higher concentrations of alanine aminotransferase within the reference interval predict nonalcoholic fatty liver disease. Clinical Chemistry, 53, 686–692.PubMedCrossRefGoogle Scholar
  13. Chen, P. H., Chen, J. D., & Lin, Y. C. (2009). A better parameter in predicting insulin resistance: Obesity plus elevated alanine aminotransferase. World Journal of Gastroenterology, 15, 5598–5603.PubMedCrossRefGoogle Scholar
  14. Conigrave, K. M., Davies, P., Haber, P., & Whitfield, J. B. (2003). Traditional markers of excessive alcohol use. Addiction, 98, 31–43.PubMedCrossRefGoogle Scholar
  15. Conway, B., & Rene, A. (2004). Obesity as a disease: No lightweight matter. Obesity Reviews, 5, 145–151.PubMedCrossRefGoogle Scholar
  16. Day, C. P. (1997). Alcoholic liver disease: Dose and threshold–new thoughts on an old topic. Gut, 41, 857–858.PubMedCrossRefGoogle Scholar
  17. Diehl, A. M. (2010). Hepatic complications of obesity. Gastroenterology Clinics of North America, 39, 57–68.PubMedCrossRefGoogle Scholar
  18. Dolman, J. M., & Hawkes, N. D. (2005). Combining the audit questionnaire and biochemical markers to assess alcohol use and risk of alcohol withdrawal in medical inpatients. Alcohol and Alcoholism, 40, 515–519.PubMedCrossRefGoogle Scholar
  19. Ely, M., Hardy, R., Longford, N. T., & Wadsworth, M. E. J. (1999). Gender differences in the relationship between alcohol consumption and drink problems are largely accounted for body water. Alcohol and Alcoholism, 34, 894–902.PubMedCrossRefGoogle Scholar
  20. Fabricatore, A. N. (2007). Behavior therapy and cognitive-behavioral therapy of obesity: Is there a difference? Journal of the American Dietetic Association, 107, 92–99.PubMedCrossRefGoogle Scholar
  21. Flegal, K. M., Carroll, M. D., Ogden, C. L., & Curtin, L. R. (2010). Prevalence and trends in obesity among US adults, 1999–2008. The Journal of the American Medical Association, 303, 235–241.CrossRefGoogle Scholar
  22. Ford, E. S., Li, C., Zhao, G., & Tsai, J. (2010). Trends in obesity and abdominal obesity among adults in the United States from 1999–2008. International Journal of Obesity (Online First). doi:10.1038/ijo.2010.186.
  23. Ford, E. S., Schulze, M. B., Bergmann, M. M., Thamer, C., Joost, H. G., & Boeing, H. (2008). Liver enzymes and incident diabetes: Findings from the European prospective investigation into cancer and nutrition (EPIC)-potsdam study. Diabetes Care, 31, 1138–1143.PubMedCrossRefGoogle Scholar
  24. Foster, G. D., Makris, A. P., & Bailer, B. A. (2005). Behavioral treatment of obesity. The American Journal of Clinical Nutrition, 82, 230S–235S.PubMedGoogle Scholar
  25. Giboney, P. T. (2005). Mildly elevated liver transaminase levels in the asymptomatic patient. American Family Physician, 71, 1105–1110.PubMedGoogle Scholar
  26. Gramenzi, A., Caputo, F., Biselli, M., Kuria, F., Loggi, E., Andreone, P., et al. (2006). Review article: Alcoholic liver disease–pathophysiological aspects and risk factors. Alimentary Pharmacology & Therapeutics, 24, 1151–1161.CrossRefGoogle Scholar
  27. Gregg, E. W., Cheng, Y. J., Cadwell, B. L., Imperatore, G., Williams, D. E., Flegal, K. M., et al. (2005). Secular trends in cardiovascular disease risk factors according to body mass index in US adults. The Journal of the American Medical Association, 293, 1868–1874.CrossRefGoogle Scholar
  28. Grundy, S. M., Cleeman, J. I., Daniels, S. R., Donato, K. A., Eckel, R. H., Franklin, B. A., et al. (2005). Diagnosis and management of the metabolic syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation, 112, 2735–2752.PubMedCrossRefGoogle Scholar
  29. Guh, D., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C. L., & Anis, A. (2009). The incidence of co-morbidities related to obesity and overweight: A systematic review and meta-analysis. BMC Public Health, 9, 88.PubMedCrossRefGoogle Scholar
  30. Hammond, R. A., & Levine, R. (2010). The economic impact of obesity in the United States. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 3, 285–295.Google Scholar
  31. Hart, C. L., Morrison, D. S., Batty, G. D., Mitchell, R. J., & Davey Smith, G. (2010). Effect of body mass index and alcohol consumption on liver disease: Analysis of data from two prospective cohort studies. BMJ, 340, c1240.PubMedCrossRefGoogle Scholar
  32. Huang, T. T., & Glass, T. A. (2008). Transforming research strategies for understanding and preventing obesity. The Journal of the American Medical Association, 300, 1811–1813.CrossRefGoogle Scholar
  33. Hughes, S. C., Chambers, C. D., Kassem, N., Wahlgren, D. R., Larson, S., Riley, E. P., et al. (2009). Inconsistent report of pre-pregnancy-recognition alcohol use by Latinas. Maternal and Child Health Journal, 13, 857–864.PubMedCrossRefGoogle Scholar
  34. Johnson, S. S., Paiva, A. L., Cummins, C. O., Johnson, J. L., Dyment, S. J., Wright, J. A., et al. (2008). Transtheoretical model-based multiple behavior intervention for weight management: Effectiveness on a population basis. Preventive Medicine, 46, 238–246.PubMedCrossRefGoogle Scholar
  35. Kim, H. C., Nam, C. M., Jee, S. H., Han, K. H., Oh, D. K., & Suh, I. (2004). Normal serum aminotransferase concentration and risk of mortality from liver diseases: Prospective cohort study. BMJ, 328, 983.PubMedCrossRefGoogle Scholar
  36. Korn, E., & Graubard, B. (1999). Analysis of health surveys. New York: John Wiley and Sons, Inc.CrossRefGoogle Scholar
  37. Lee, T. H., Kim, W. R., Benson, J. T., Therneau, T. M., & Melton, L. J., 3rd. (2008). Serum aminotransferase activity and mortality risk in a United States community. Hepatology, 47, 880–887.PubMedCrossRefGoogle Scholar
  38. Li, C., Ford, E. S., Zhao, G., Balluz, L. S., & Giles, W. H. (2009). Estimates of body composition with dual-energy X-ray absorptiometry in adults. The American Journal of Clinical Nutrition, 90, 1457–1465.PubMedCrossRefGoogle Scholar
  39. Mason, J., Starke, R., & Van Kirk, J. (2010). Gamma-glutamyl transferase: A novel cardiovascular risk biomarker. Preventive Cardiology, 13, 36–41.PubMedCrossRefGoogle Scholar
  40. McIntosh, J. (2008). Is alcohol consumption good for you? Results from the 2005 Canadian community health survey. Addiction Research and Theory, 16, 553–563.CrossRefGoogle Scholar
  41. Morris, M. J. (2008). Cardiovascular and metabolic effects of obesity. Clin Exp Physiology and Pharmacology, 35, 416–419.CrossRefGoogle Scholar
  42. NACB. (2000). Laboratory medicine practice guidelines: Laboratory guidelines for screening, diagnosis and monitoring of hepatic injury. The National Academy of Clinical Biochemistry (NACB). Washington, DC.Google Scholar
  43. NIAAA. (1997). Alcohol alert: Alcohol metabolism. No. 35. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Rockville, MD.Google Scholar
  44. NIAAA. (1999). Alcohol alert: Are women more vulnerable to alcohol’s effects? National Institute on Alcohol Abuse and Alcoholism (NIAAA). No. 46. Rockville, MD.Google Scholar
  45. NIAAA. (2004). Binge drinking defined. Newsletter, Winter 2004, Number 3. National Institute on Alcohol Abuse and Alcoholism, National Institute of Health, US Department of Health and Human Services. Rockville, Maryland.Google Scholar
  46. NIAAA. (2005). National Institute on alcohol abuse and alcoholism. Helping patients who drink too much: A Clinician’s Guide. NIH Pub No. 05-3769. Bethesda, MD.Google Scholar
  47. Nijem, K., Kristensen, P., Al-Khatib, A., & Bjertness, E. (2005). Application of different statistical methods to estimate relative risk for self-reported health complaints among shoe factory workers exposed to organic solvents and plastic compounds. Norwegian Journal of Epidemiology, 15, 111–116.Google Scholar
  48. Nyblom, H., Berggren, U., Balldin, J., & Olsson, R. (2004). High AST/ALT ratio may indicate advanced alcoholic liver disease rather than heavy drinking. Alcohol and Alcoholism, 39, 336–339.PubMedCrossRefGoogle Scholar
  49. Ogden, C., Yanovski, S., Carroll, M., & Flegal, K. (2007). The epidemiology of obesity. Gastroenterology, 132, 2087–2102.PubMedCrossRefGoogle Scholar
  50. Okosun, I. S., Seale, J. P., Daniel, J. B., & Eriksen, M. P. (2005). Poor health is associated with episodic heavy alcohol use: Evidence from a National Survey. Public Health, 119, 509–517.PubMedCrossRefGoogle Scholar
  51. Orzano, A. J., & Scott, J. G. (2004). Diagnosis and treatment of obesity in adults: An applied evidence-based review. The Journal of the American Board of Family Medicine, 17, 359–369.CrossRefGoogle Scholar
  52. Peterson, K. (2004). Biomarkers for alcohol use and abuse: A summary. Alcohol Research & Health, 28, 30–37.Google Scholar
  53. Pratt, D. S., & Kaplan, M. M. (2000). Evaluation of abnormal liver-enzyme results in asymptomatic patients. The New England Journal of Medicine, 342, 1266–1271.PubMedCrossRefGoogle Scholar
  54. Puukka, K., Hietala, J., Koivisto, H., Anttila, P., Bloigu, R., & Niemela, O. (2006). Additive effects of moderate drinking and obesity on serum gamma-glutamyl transferase activity. The American Journal of Clinical Nutrition, 83, 1351–1354; quiz 1448–1359.Google Scholar
  55. Rehm, J., Room, R., Graham, K., Monteiro, M., Gmel, G., & Sempos, C. T. (2003). The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: An overview. Addiction, 98, 1209–1228.PubMedCrossRefGoogle Scholar
  56. Ruhl, C. E., & Everhart, J. E. (2009). Elevated serum alanine aminotransferase and gamma-glutamyltransferase and mortality in the United States population. Gastroenterology, 136, 477–485.PubMedCrossRefGoogle Scholar
  57. Ruhl, C. E., & Everhart, J. E. (2010). Trunk fat is associated with increased serum levels of alanine aminotransferase in the United States. Gastroenterology, 138, 1346–1356, 1356 e1341–1343.Google Scholar
  58. SAMHSA. (2006). The role of biomarkers in the treatment of alcohol use disorders. Substance abuse and mental health services administration (SAMHSA). Substance Abuse Treatment Advisory, 5.Google Scholar
  59. Sato, K. K., Hayashi, T., Nakamura, Y., Harita, N., Yoneda, T., Endo, G., et al. (2008). Liver enzymes compared with alcohol consumption in predicting the risk of type 2 diabetes: The Kansai Healthcare Study. Diabetes Care, 31, 1230–1236.PubMedCrossRefGoogle Scholar
  60. Sharpe, P. C. (2001). Biochemical detection and monitoring of alcohol abuse and abstinence. Annals of Clinical Biochemistry, 38, 652–664.PubMedCrossRefGoogle Scholar
  61. St George, A., Bauman, A., Johnston, A., Farrell, G., Chey, T., & George, J. (2009). Effect of a lifestyle intervention in patients with abnormal liver enzymes and metabolic risk factors. Journal of Gastroenterology and Hepatology, 24, 399–407.PubMedCrossRefGoogle Scholar
  62. Stockwell, T., Donath, S., Cooper-Stanbury, M., Chikritzhs, T., Catalano, P., & Mateo, C. (2004). Under-reporting of alcohol consumption in household surveys: A comparison of quantity-frequency, graduated-frequency and recent recall. Addiction, 99, 1024–1033.PubMedCrossRefGoogle Scholar
  63. Stranges, S., Dorn, J. M., Muti, P., Freudenheim, J. L., Farinaro, E., Russell, M., et al. (2004a). Body fat distribution, relative weight, and liver enzyme levels: A population-based study. Hepatology, 39, 754–763.PubMedCrossRefGoogle Scholar
  64. Stranges, S., Freudenheim, J. L., Muti, P., Farinaro, E., Russell, M., Nochajski, T. H., et al. (2004b). Differential effects of alcohol drinking pattern on liver enzymes in men and women. Alcoholism, Clinical and Experimental Research, 28, 949–956.PubMedCrossRefGoogle Scholar
  65. Stranges, S., Notaro, J., Freudenheim, J. L., Calogero, R. M., Muti, P., Farinaro, E., et al. (2006). Alcohol drinking pattern and subjective health in a population-based study. Addiction, 101, 1265–1276.PubMedCrossRefGoogle Scholar
  66. Sullivan, P. W., Ghushchyan, V., & Ben-Joseph, R. H. (2008). The effect of obesity and cardiometabolic risk factors on expenditures and productivity in the United States. Obesity (Silver Spring), 16, 2155–2162.CrossRefGoogle Scholar
  67. Targher, G. (2010). Elevated serum gamma-glutamyltransferase activity is associated with increased risk of mortality, incident type 2 diabetes, cardiovascular events, chronic kidney disease and cancer—a narrative review. Clinical Chemistry and Laboratory Medicine, 48, 147–157.PubMedCrossRefGoogle Scholar
  68. Tsai, J., Floyd, R. L., & O’ Connor, M. J. (2008). Paradigms for alcohol use and co-occurring behavioral health risk factors among women of childbearing age. In K. I. DiGuarde (Ed.), Binge drinking research progress (pp. 87–100). Hauppauge, NY: Nova Science Publishers, Inc.Google Scholar
  69. Tsai, J., Ford, E. S., Li, C., Pearson, W. S., & Zhao, G. (2010a). Binge drinking and suboptimal self-rated health among adult drinkers. Alcoholism, Clinical and Experimental Research, 34, 1–7.CrossRefGoogle Scholar
  70. Tsai, J., Ford, E. S., Li, C., Zhao, G., Pearson, W. S., & Balluz, L. S. (2010b). Multiple healthy behaviors and optimal self-rated health: Findings from the 2007 Behavioral Risk Factor Surveillance System Survey. Preventive Medicine, 51, 268–274.PubMedCrossRefGoogle Scholar
  71. USPSTF. (2004). Screening for obesity in adults: Recommendations and rationale. American Journal of Nursing, 104, 94–95, 97–98, 100.Google Scholar
  72. Valencia-Martin, J. L., Galan, I., & Rodriguez-Artalejo, F. (2009). Alcohol and self-rated health in a Mediterranean country: The role of average volume, drinking pattern, and alcohol dependence. Alcoholism, Clinical and Experimental Research, 33, 240–246.PubMedCrossRefGoogle Scholar
  73. Vanbuskirk, K., & Potenza, M. (2010). The treatment of obesity and its co-occurrence with substance use disorders. Journal of Addiction Medicine, 4, 1–10.PubMedCrossRefGoogle Scholar
  74. Visscher, T. L., & Seidell, J. C. (2001). The public health impact of obesity. Annual Review of Public Health, 22, 355–375.PubMedCrossRefGoogle Scholar
  75. Vozarova, B., Stefan, N., Lindsay, R. S., Saremi, A., Pratley, R. E., Bogardus, C., et al. (2002). High alanine aminotransferase is associated with decreased hepatic insulin sensitivity and predicts the development of type 2 diabetes. Diabetes, 51, 1889–1895.PubMedCrossRefGoogle Scholar
  76. WHO. (2000). Obesity: Preventing and managing the global epidemic. The World Health Organization (WHO) Technical Report. Series 894.Google Scholar
  77. Zhao, G., Ford, E. S., Li, C., & Mokdad, A. H. (2009a). Weight control behaviors in overweight/obese US adults with diagnosed hypertension and diabetes. Cardiovascular Diabetology, 8, 13.PubMedCrossRefGoogle Scholar
  78. Zhao, G., Ford, E. S., Li, C., Strine, T. W., Dhingra, S., Berry, J. T., & Mokdad, A. H. (2009b). Serious psychological distress and its associations with body mass index: Findings from the 2007 behavioral risk factor surveillance system. International Journal of Public Health, 54, 30–36.Google Scholar

Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2011

Authors and Affiliations

  • James Tsai
    • 1
  • Earl S. Ford
    • 1
  • Guixiang Zhao
    • 1
  • Chaoyang Li
    • 1
  • Kurt J. Greenlund
    • 1
  • Janet B. Croft
    • 1
  1. 1.Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and PreventionAtlantaUSA

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